Medical-Surgical Nursing
coli, enterobacter, Pseudomonas &
RENAL / URINARY SYSTEM
Take note:
● Everytime you urinate, you
excreted out potassium.
● If you have problems with your
kidneys, you may suffer from
metabolic acidosis.
● Patients who have acute/chronic
renal failure may suffer from
hyperkalemia.
● Kidney is also the one responsible
for the initiation of production of
erythropoietin. Which is essential
for the bone marrow to produce
red blood cells.
● Without erythropoietin, bone
marrow doesn’t have the ability to
produce red blood cells.
Two types of Erythropoietin
● Given subcutaneously in exogenous
form or IV
1. Erythropoietin alpha
2. Erythropoietin beta
● When giving erythropoietin, do not
massage or aspirate the injection
site.
GENITOURINARY DISORDER
CYSTITIS
Inflammation of the bladder
Clinical findings:
1. Abdominal or flank pain / tenderness
2. Frequency and urgency of urination
● Residual urine volume - the
amount of urine that remains in your
bladder after you urinate.
3. Pain on voiding
4. Nocturia
5. Fever
Notes by: Sherilyn Encinares
6. Most common causative agent: E.
Serratia
● Common cause of cystitis/UTI:
Bubble bath; sexual practices
Diagnostic Tests:
1. Urine culture and sensitivity - no
more antibiotics
● Presence of E. coli (80%)
Nursing Care:
1. Force fluids - 3L/day; cannot
perform to patients with Intracranial
Pressure (ICP)
2. Warm sitz bath for comfort
3. Assess urine for odor, hematuria, and
sediment
4. Use strict aseptic technique in
Bladder Catheter
5. Administer medications as ordered.
6. Client teaching
Client Teaching:
1. Acidic urine diminish the action of
aminoglycoside, sulfonamide,
nitrofurantoin (macrodantin)
2. Discourage caffeine products such as
coffee, tea and cola
3. Avoid alcohol
4. Wipe perineal area from front to back
5. Void and drink a glass of water after
intercourse
6. Void q 2H
7. Encourage menopausal women to use
estrogen vaginal creams to restore pH
8. Instruct female client to use
water-soluble lubricants for coitus,
especially after menopause.
BLADDER CANCER
Assessment Findings:
1. Intermittent, painless hematuria
2. Dysuria
3. Frequent urination
Diagnostic Tests:
1
 1. Cystoscopy with biopsy reveals
malignancy
2. Cytologic exam of the urine reveals
malignant cells
Management:
1. Cystectomy
● Removal of the urinary bladder
2. Bladder Surgery
3. Kock Pouch
● Continent internal ileal reservoir
created from a segment of the
ileum & ascending colon
● Ureters are implanted into the
side of the reservoir & a special
nipple valve is constructed to
attach the reservoir to the skin.
● Postoperatively, the client will
have a g. 24 to 26 foley catheter
in place to drain urine
continuously until the pouch has
healed.
● Teach client how to
self-catheterize & to drain the
reservoir at 5-6H intervals
Nursing Care: PRE-OP
1. Provide routine pre-op care
2. Assess the client's ability to learn
prior to starting a teaching.
3. Discuss social aspects of living with a
stoma
● Sexuality, changes in body image
● Bowel prep for procedures
involving the ileum or colon.
4. Inform client of post-op procedures
Nursing Care: POST-OP
1. Provide routine post-op care
2. Maintain integrity of the stoma
3. Monitor for and report signs of
impaired stomal healing
4. Prevent skin irritation and breakdown
5. Inspect skin areas for signs of
breakdown daily
6. Change appliances only when
necessary and when production of urine
is slowest. (early morning)
7. Place wick (rolled gauze pad) on
Notes by: Sherilyn Encinares
stomal opening when appliance is off.
8. Cleanse peristomal skin with mild
soap and water
9. Remove alkaline encrustations by
applying vinegar and water solution to
periostomal area.
10. Implement measures to maintain
urine acidity
● Acid-ash foods
● Vitamin C
● Omission of milk/dairy products
11. Provide client teaching and
discharge planning concerning:
● Maintenance of stomal /
periostomal skin integrity
● Proper application of appliance
● Recommended method of
cleaning reusable ostomy
equipment - manufacturer’s
recommendations
● Information regarding prevention
of UTIs
● Adequate fluids
● Empty pouch when half full
● Change to bedside bag at night
● Control of odor
NEPHROLITHIASIS
1. Presence of stones anywhere in the
urinary tract
2. Frequent compositions of stones:
● Calcium, uric acid and cystine
stones
3. Most often occurs in men age 20-55
years
4. Deficiency in Mg, Citrate,
Nephrocalcin, uropontin
Predisposing factors:
1. Fluid status
2. Diet: large amount of calcium,
oxalate
3. Increased uric acid levels
4. Infection
5. Sedentary lifestyles, immobility
6. Family history of gout or calculi
7. Hyperparathyroidism
8. 75% → Ca stones
9. → HyperPara, ↑ Vitamin D, ↑ Milk and
2
 alkali in diet 5. ↑ Na → ↑ Ca in the urine
10. 15% → Struvite “infection stones” 6. Achieved by eliminating milk/dairy
● Proteus, Pseudomonas, products
Klebsiella, Staphylococcus 7. Provide acid-ash diet to acidify urine
11. 5-10% → Uric acid stones ● Cranberry or prune juice
12. → Gout ● Meat
13. 1% → Cysteine → inherited defect in ● Eggs
absorption of cysteine (amino acid) ● Poultry
14. Stones may also result from ● Fish
patients with IBD, colostomy, ileostomy ● Grapes
● Whole grains
8. Cellulose Na PO4
Clinical findings: ● Binds Ca in the GIT

1. Abdominal pain or flank pain

2. Renal colic OXALATE STONES → alkaline
● Severe pain in the kidney area
radiating down the flank to the 1. Avoid excess intake of foods/fluids
pubic area high in oxalate
3. Hematuria, frequency, urgency, 2. → Tea, Chocolate, Rhubarb, Spinach,
nausea Strawberry, Peanuts and wheat
4. History of prior associated health 3. ↑ OFI to dilute urine
problems 4. Maintain alkaline-ash diet to
5. Diaphoresis alkalinize urine
6. Pallor
7. Grimacing
8. Vomiting URIC ACID STONES → acidic
9. Pyuria if infection is present
1. Uric acid is a metabolic product of
Diagnostics: purines
2. Reduce foods high in purine
1. U/A
● Liver, brains, kidneys, venison,
2. KUB U/S
shellfish, meat soups, gravies,
3. IVP, RGP
legumes and whole grains,
4. 24 H urine test for Ca, Uric Acid,
beer/wine
Creatinine
3. Maintain alkaline urine
4. Allopurinol
Management:

1. Goal: eradicate stone, prevent

nephron destruction, control infection, MANAGEMENT FOR STONE
relieve obstruction FORMATION
● Supportive
Surgery

1. Percutaneous nephrostomy
CALCIUM STONES
2. Percutaneous ultrasonic lithotripsy
(PUL)
1. Type II absorptive calciuria (50%)
3. Extracorporeal shock-wave lithotripsy
2. Controversial!!!
(ESWL)
3. ↑ OFI, ↓ Na, CHON
● Electromagnetically generated
4. ↑ CHON → ↑ urinary excretion of Ca
shock waves are focused over
and uric acid
the area of the renal stone

Notes by: Sherilyn Encinares

3
 ● Repeated shocks
● This procedure is non-invasive
● Nephrolithotomy
● Open surgical procedure to
evacuate stones
Nursing Care
1. Encourage daily weight-bearing
exercise
2. Provide client teaching and discharge
planning concerning:
● Adherence to prescribed diet
● Need for routine U/A
● Need for recognize and report
S/Sx of recurrence
PYELONEPHRITIS
● Inflammation of the renal pelvis
& parenchyma, commonly
caused by bacterial invasion
Acute Infection
● Usually ascends from the lower
urinary tract or following an
invasive procedure of the urinary
tract
● Can progress to bacteremia or
chronic pyelonephritis
Assessment
1. Fever & chills
2. N/V
3. CVA tenderness, flank pain on the
affected side
4. Headache, muscular pain, dysuria
5. Frequency & urgency
Chronic Infection
● Major cause is ureterovesical
reflux
● Result of recurrent infections is
eventual parenchymal
deterioration and possible renal
failure
Assessment
Notes by: Sherilyn Encinares
1. Client usually unaware of the disease
2. May have bladder irritability
3. Chronic fatigue
4. Slight dull ache over the kidneys
5. Eventually develops hypertension,
atrophy of the kidneys
6. Azotemia
Nursing Care
1. Monitor I & O
2. ↑ OF
3. Encourage adequate rest
4. Administer antibiotics, analgesics as
ordered
5. Support client and significant others
6. Provide client teaching and discharge
planning:
● Diet: high calorie, low protein
ACUTE RENAL FAILURE
● Sudden, almost complete loss of
renal function over a period of
hours to days
● Reversible
● Causes:
❖ Pre-renal (cardiac issue)
❖ Renal (pathology is in the
kidney)
❖ Post-renal (obstructions in
the urine flow)
Stages of Acute Renal Failure:
1. Initiation - initial in salt and end into
oliguria
2. Oliguric phase - last 1-3 weeks with
a urine output of less than 400 cc/day; ↑
BUN, ↑ Creatinine, ↑ Uric acid, ↑
Potassium, ↑ Magnesium, ↑ Phosphate, ↑
Calcium and ↓ Sodium; client will have
an edema and hypertension
3. Diuretic phase - begins after a week
of oliguric phase and last up to 1 week;
↑ urine output (3-5 L/day); risk for
hypokalemia (monitor the client’s
potassium level)
4. Recovery phase - kidney is trying to
recover; avoid toxic (drugs)
4
 4. NaHCO3
5. Al(OH)3
6. Albumin IV

CHRONIC RENAL FAILURE

● Progressive, irreversible
deterioration in renal fx. in which
the body’s ability to maintain
metabolic and f-e-b fails
● Continues until nephrons are
replaced by scar tissue

Predisposing factors

1. Recurrent infections
2. Exacerbations of nephritis
3. Urinary tract obstructions
4. Diabetes mellitus
5. Hypertension

Stages of CRF

1. ↓ Renal reserve - GFR = 40-50%

2. Renal insufficiency - GFR = 20-40%
Management 3. Renal failure - GFR = 10-20%
4. End stage renal disease (ESRD) - GFR
Goal: restore normal chemical balance, = ↓ 10%
prevent complications until full recovery
● Kidneys Assessment
● SUPPORTIVE: support renal fx.
thru crisis 1. Loss of kidney’s ability to excrete
1. Fluid balance metabolic waste products of CHON thru
❖ I & O, feces, urine production
gastric/wound 2. OLIGURIA - progressing
drainage, 3. ↑ BUN, Creatinine
perspiration 4. Uremic fetor
2. IVF, blood transfusion 5. HPN (RAAS), heart failure, pulmonary
3. Preventing infection edema, pericarditis
4. Appropriate ventilatory 6. Uremic frost
measures 7. Anorexia, n/v, pain, hiccups
5. Diet 8. ↓ LOC, weakness, confusion
6. Reducing metabolic rate 9. Renal osteodystrophy - ↓ Ca, ↑ Po4, ↑
7. Skin care PTH, ↓ Vitamin D
8. DIALYSIS 10. Metabolic acidosis
● Pharmacologic:
1. Diuretics
2. Kayelexate,
glucose+insulin, retention
enemas, Ca gluconate
3. Low dose dopamine

Notes by: Sherilyn Encinares

5
 Signs and symptoms DIALYSIS

● Removal by artificial means of

metabolic wastes, excess
electrolytes and excess fluid from
clients with renal failure.

Principles

1. Diffusion
2. Osmosis
3. Ultrafiltration
4. Dialysate
5. “Dialysate bath”
6. Adjust electrolyte levels (NaHCO3,
Diagnostic tests Acetate

● BUN, Creatinine, electrolytes, Purposes

CBC, urinalysis
1. Remove the end products of protein
Medical management metabolism from blood.
2. Maintain safe levels of electrolytes
1. Diet restrictions 3. Correct acidosis and replenish the
2. ↑ caloric acid, ↑ CHO, ↓ K, ↑ Ca, ↓ PO4 blood bicarbonate system
3. ↓ / restrict CHON 4. Remove excess fluid from the blood
4. Multivitamins
5. Fluid intake Types
6. Hemodialysis
1. Hemodialysis
Pharmacologic management 2. Peritoneal dialysis

1. ANTACIDS
● Hypocalcemia HEMODIALYSIS
● Hyperphosphatemia
● Mg based antacids ● Shunting of blood from the pt
2. Anti-HPN vascular system through an
3. Anti-seizure artificial dialyzing system and
4. Erythropoietin return of dialyzed bld to the pt
circulation.
Nursing Care
Venous Access
1. Maintain FEB
● I & O, Wt, edema, breath 1. Venous catheters
sounds, fluids 2. AV Fistula
2. Prevent neurologic complications 3. Graft
3. Promote optimal GI function
4. Provide comfort → REST!!! Nursing Care
5. Monitor for bleeding complications
and prevent injury 1. Have client void
6. Provide care for client receiving 2. Chart client’s weight, V/S, lab values
dialysis ● Withhold antihypertensives,
sedatives and vasodilators

Notes by: Sherilyn Encinares

6
 3. Ensure bed rest with frequent
position changes for comfort
4. Inform client that headache and
nausea may occur
5. Monitor closely for signs of bleeding
since blood has been heparinized for
procedure
Nursing Care: POST-DIALYSIS
1. Chart client’s weight, V/S
Assess for complications:
1. Hypovolemic shock
2. Dialysis disequilibrium syndrome
3. Assess for nausea, vomiting, HPN
disorientation, leg cramps, and
peripheral paresthesias
Criteria for successful hemodialysis
1. ↓ weight
2. (-) complaint of pain
3. Adheres to prescribed activity level
4. Eats according to preference during
therapy
5. Correctly explains dialysis
Complications
1. Hepa B/C
2. Atherosclerotic cardiovascular disease
3. Clotting
● Adjust heparin
4. GIT problems
5. Sleep problems
● Adjust temperature of dialysate
● Limiting napping time
6. Hypotension
● Painful muscle cramping
7. Drug toxicity
PERITONEAL DIALYSIS
1. Introduction of a specially prepared
dialysate solution into the abdominal
cavity, where the peritoneum acts as a
semipermeable membrane between the
dialysate and blood into the abdominal
vessels.
2. Takes 36-48H to achieve what HD
Notes by: Sherilyn Encinares
achieves in 6-8H
3. Diffusion, Osmosis, Ultrafiltration
Advantages
1. Provides a steady state of blood
chemistries
2. Can be performed alone in any
location without aid of a machine
3. Easily taught and learned
4. Has few dietary restrictions
5. Can be used for patients who are
hemodynamically unstable
6. Treatment of choice for those
unwilling to undergo HD and kidney
transplant
Nursing care
1. Tenckhoff catheter
2. Chart client’s weight
3. Assess V/S before, q15 min during
first exchange and qH thereafter
4. Assemble specially prepared dialysate
solution with added medications
5. Have client void
6. Warm dialysate solution to body
temperature
7. Inflow: allow dialysate to flow
unrestricted into peritoneal cavity
8. 10-20 minutes
9. Dwell: allow fluid to remain in
peritoneal cavity for prescribe period
10. 30-45 minutes
11. Drain: unclamp outflow tube and
allow to flow by gravity
Special considerations:
● Heparin
● Potassium chloride
● Antibiotics
● Insulin
● Give all medications before
solution is instilled
● Monitor complications
12. Observe characteristics of dialysate
outflow
● Colorless, straw-colored / pale
yellow
● Cloudy
● Brownish
7
 ● Blood
Continuous Ambulatory Peritoneal
Dialysis
● A continuous type of peritoneal
dialysis at home by the client or
significant others
● Dialysate is delivered from
flexible plastic containers
through a permanent peritoneal
catheter
● Following infusion of the
dialysate into the peritoneal
cavity, the bag is folded and
tucked away during the dwell
period
● Performed q 4-5x a day, 24
hrs/day, 7 days a week
13. Provide client teaching and
discharge planning concerning:
14. Need to assess the permanent
peritoneal catheter for complications:
15. Adherence to high-protein (if
indicated), well-balanced diet.
16. Importance of periodic blood
chemistries
17. Daily weights
Nursing considerations
1. Disturbance in body image,
self-esteem
● Increased in waist line
2. Disruption of sexual activity
3. Frustration
KIDNEY TRANSPLANTATION
1. Transplantation of a kidney from a
donor to recipient to prolong the life of
person with renal failure
2. Treatment of choice for ESRD patient
SOURCES OF DONOR SELECTION
1. Living relative with compatible serum
Notes by: Sherilyn Encinares
and tissue studies, free from systemic
infection and emotionally stable
2. Cadavers with good serum and tissue
cross matching, free from renal disease,
neoplasm and sepsis, absence of
ischemia/trauma.
Nursing Care: PRE-OP
1. Provide routine pre-op care
2. Ensure that the metabolic state of
patient is at level close to manual
3. Free of infection
4. Discuss the possibility of post-op
dialysis/immunosuppressive drug
therapy with clients and significant
others.
5. Labs: blood typing, tissue typing,
antibody screening
Nursing Care: POST OP
1. Provide routine post-op care
2. Monitor fluid and electrolyte balance
carefully
● Monitor input and output and
adjust IV fluid administration
accordingly
● Anticipate possible massive
diuresis
❖ Relatives - diuresis, fx
❖ Cadaver - acute tubular
necrosis, anuria, 2-3 days
fx
3. Encourage frequent and early
ambulation
4. Monitor V/S especially temperature
and report significant changes
5. Provide mouth care and nystatin
(myostatin) mouthwashes for
candidiasis
6. Administer immunosuppressive
agents as ordered
IMMUNOSUPPRESSIVE THERAPY
1. Survival rate of kidney transplant
depends on the ability to block the
body’s immune response to the
transplanted kidney
2. Assess client for transplant rejection:
8
 ● Oliguria, fever, edema, ↑ BP,
weight gain
Nursing Care: POST OP
1. Assess for signs of rejection
2. Provide client teaching and discharge
planning concerning:
● Medication regimen
● S/Sx of tissue rejection and the
need to
● Report it immediately to the
physician
● Dietary restrictions
● Restricted Na and calories
● Increased CHON
● Daily weights
● Daily measurement of I & O
● Resumption of activity and
avoidance of contact sports in
which the transplanted kidney
may be injured
NEPHRECTOMY
1. GENERAL INFORMATION
● Surgical removal of an entire
kidney
Indications
1. Renal tumor
2. Massive trauma
3. Removal for a donor
4. Polycystic kidneys
Nursing Care: PRE-OP
1. Provide routine pre-op care
2. Ensure adequate fluid intake
Notes by: Sherilyn Encinares
3. Assess electrolyte values and correct
any imbalances before surgery
4. Avoid nephrotoxic agents in any
diagnostic tests
5. Advise client to expect flank pain
after surgery if retroperitoneal approach
(flank incision) is used
6. Explain that the client will have chest
tube if thoracic approach is used
Nursing Care: POST OP
1. Provide routine post-op care
2. Assess urine output every hour
3. Observe urinary drainage on dressing
and estimate amount
4. Weigh daily
5. Maintain adequate functioning of
chest drainage, ensure adequate
oxygenation and prevent pulmonary
complications
6. Administer analgesics as ordered
7. Encourage early ambulation
8. Teach client to splint incision while
turning, coughing and deep breathing
Teach client teaching and discharge
planning concerning:
1. Prevention of urinary stasis
2. Maintenance of acidic urine
3. Avoidance of activities that might
cause trauma to remaining kidney
4. Contact sports, horseback riding
5. No lifting of heavy objects for at least
6 months
6. Need to report unexplained weight
gain, decreased urine output, flank pain
on unoperative side, hematuria
7. Need to notify physician if cold or
other infection present for more than 3
days
8. Medication regimen and avoidance of
OTC drugs that may be nephrotoxic
BENIGN PROSTATIC HYPERTROPHY
1. Most common problem of the male
reproductive system
2. Occurs in 50% of men over age 50
3. 75% of men over age 75
9
 Etiology Nursing Care: PRE-OP

1. Unknown 1. Provide routine pre-op care

2. May be related to hormonal 2. Information about the procedure and
mechanism the expected post-op care, including
catheter drainage, irrigation and
Clinical findings monitoring of hematuria is discussed
3. Reinforce what surgeon has told
1. Nocturia client/significant others regarding
2. Frequency effects of surgery on sexual function
3. Decreased force and amount of 4. Bowel prep
urinary stream 5. Force fluids: administer antibiotics,
4. Hesitancy acid-ash diet
5. Hematuria
6. Enlargement of prostate gland upon Nursing Care: POST OP
palpation by digital rectal exam
1. Provide routine post-op care
Diagnostic tests 2. Maintain patency of urethral catheter
placed after surgery
1. Urinalysis 3. Turp
● Alkalinity increased ● Maintain traction on 3 way
● Specific gravity normal or catheter
increased 4. Relieve pain
2. BUN and creatinine increased 5. Reduce anxiety
3. Prostate-specific antigen (PSA) 6. Health education and health
elevated maintenance
● Normal: <4 ng/ml
4. Cystoscopy Complications
5. Prostate UTZ
1. Hemorrhage
Nursing Care 2. Infection
3. Obstructed catheter
1. Administer antibiotics as ordered 4. Sexual dysfunction
2. Provide client teaching concerning

Medications: URINARY TRACT INFECTION

● Terazosin (Hytrin)
● Finasteride (Proscar) Predisposing factors:
1. Poor hygiene
2. Irritation from bubble baths
PROSTATIC SURGERY 3. Urinary reflux
4. Women
1. Indicated for benign prostatic
hypertrophy and prostatic cancer Clinical findings

Types 1. Low-grade fever, chills

2. Abdominal pain - suprapubic, low
1. Transurethral resection back pain
2. Suprapubic prostatectomy 3. Enuresis
3. Retropubic prostatectomy 4. Pain/burning on urination
4. Perineal prostatectomy 5. Frequency
6. Hematuria

Notes by: Sherilyn Encinares

10
 7. Foul smelling urine Nursing Care: PRE OP
8. Enuresis
1. Monitor V/S frequently
Diagnosis: 2. Monitor for F/E imbalances including
● U/A dehydration after the obstruction is
relieved.
Nursing Care 3. Monitor diuresis w/c could lead to
fluid depletion
1. Obtain cultures before starting 4. Monitor urine for specific gravity,
antibiotics albumin & glucose
2. Administer antibiotics as ordered 5. Administer fluid replacement as
3. Provide warm baths and allow child to prescribed
void in water to alleviate painful voiding
4. Force fluids Nursing Care: POST OP
5. Encourage measures to acidify urine
6. Hot sitz bath 1. Monitor drains
7. Empty bladder q 2-3H ● May have one from bladder and
8. Empty bladder after intercourse one from each ureter (ureteral
stents)
Pharmacologic 2. Check output from all drains and
record carefully
1. Antibiotics ● Expect bloody urine initially
● Cephalosporins 3. Observe drainage from abdominal
2. Urinary antiseptics dressing and note color, amount and
● Nitrofurantoin frequency
● Nalidixic acid 4. Administer medication for bladder
3. Urinary analgesics spasms as ordered
● Phenazopyridine (pyridium) 5. Monitor urine for specific gravity,
4. Cholinergics albumin & glucose
● Bethanechol (urecholine) 6. Administer fluid replacement as
prescribed

HYDRONEPHROSIS
SPINAL NEEDLE
Dilatation of the renal pelvis and calyces
of one or both kidneys due to 1. G. 18 - Pink
obstruction 2. G. 19 - Beige
3. G. 20 - Yellow
Clinical findings 4. G. 21 - Green
5. G. 22 - Black
1. Repeated UTIs 6. G. 23 - Blue
2. Failure to thrive 7. G. 24 - Violet
3. Abdominal/flank pain, fever, chills 8. G. 25 - Orange
4. Fluctuating mass in region of kidney 9. G. 26 - Brown
10. G. 27 - Gray
Medical management 11. G. 28 - Red
1. Antibiotics
2. Surgery to correct or remove
obstruction
3. Nephrostomy
4. Nephrectomy

Notes by: Sherilyn Encinares

11